The law restricts health care for asylum seekers currently during the first 18 months of stay to instances ‘of acute diseases or pain’, in which ‘necessary medical or dental treatment has to be provided including medication, bandages and other benefits necessary for convalescence, recovery, or alleviation of disease or necessary services addressing consequences of illnesses.[1] Furthermore, vaccination and ‘necessary preventive medical check-ups’ shall be provided.[2] The law further contains a special provision for pregnant women and women who have recently given birth. They are entitled to ‘medical and nursing help and support’, including midwife assistance.[3] In addition, the law states that further benefits can be granted ‘if they are indispensable in an individual case to secure health’.[4]
After 18 months, asylum seekers are entitled to social benefits as regulated in the Twelfth Book of the Social Code (Sozialgesetzbuch). These ‘standard’ social benefits include access to health care under the same conditions that apply to German citizens who receive social benefits. The waiting period of 18 months is a result of the reform of the Asylum Seekers’ Benefits Act in 2019, which extended the previous waiting period of 15 months by an additional 3 months.[5] The German Parliament has passed in January 2024 the so-called Rückführungsverbesserungsgesetz (Act to Improve Removals) which includes various measures, e.g., acceleration of removals, reduction of benefits and faster access to labour.[6] The reduction of benefits entails that asylum seekers will in the future only have access to ‘standard’ social benefits after 36 months.
The term ‘necessary treatment’ within the meaning of the law has not conclusively been defined but is often considered to mean only medical care that is absolutely unavoidable. However, the wording of the law suggests that health care for asylum seekers must not be limited to ‘emergency care’ since the law refers to acute diseases or pain as grounds for necessary treatment. Accordingly, it has been argued that a limitation of treatment to acute diseases is not in accordance with the law. If chronic diseases cause pain, they have to be treated as well.[7] There remains a dispute, however, as to what treatment is necessary in these cases, i.e. if the treatment of pain requires treatment of the causes of the chronic disease, or if a more cost-effective treatment option (usually medication) that eliminates the pain, at least temporarily, is sufficient. It has been reported that necessary but expensive diagnostic measures or therapies are not always granted by local authorities, which argue that only ‘elementary’ or ‘vital’ medical care would be covered by the law.[8] NGO’s and other stakeholders repeatedly criticise the differentiation concerning health care and the resulting discrimination.[9] Especially Federal Chamber of Psychotherapists (BPtK), medical associations and other organisations have expressed criticism due to the legal changes concerning the time extension of the reduced health care benefits.[10]
Even if a chronic disease is not causing pain momentarily, asylum seekers might still be entitled to treatment, if it is indispensable to secure their health pursuant to Section 6(1) of the Asylum Seekers’ Benefits Act. Recently, some Regional Social Courts have argued that this provision must be interpreted broadly in accordance with the constitution. Thus, apart from a few exceptions, especially in the case of minor illnesses or short stays, a level of benefits must be established that corresponds to regular health insurance.[11]
In general, the practice with regard to access to health care varies between Federal States and at times between municipalities.[12] A common problem in practice is caused by the need to obtain a health insurance voucher (Krankenschein). These vouchers or certificates are usually handed out by medical personnel in the initial reception centres, but once asylum seekers have been referred to other forms of accommodation, they usually have to apply for them at the social welfare office of their municipality. Critics have pointed out that the ambiguity of the scope of benefits under the law leads to varying interpretations in practice from municipality to municipality and may result in bureaucratic arbitrariness by case workers at the social welfare offices, who usually have no medical expertise.[13] The necessity to distribute health insurance vouchers individually also imposes significant administrative burden on the social services.
In response, the Federal States of Berlin, Brandenburg, Bremen, Hamburg, Schleswig-Holstein and Thuringia issue ‘normal’ health insurance cards to asylum seekers, enabling them to see a doctor without permission from the authorities. In some Federal States (North Rhine-Westphalia, Lower Saxony and Rhineland-Palatinate) the health insurance card for asylum seekers has been introduced in principle, but it has only been implemented in a few municipalities.[14] Other Federal States (e.g. Bavaria and Baden-Württemberg, Saxony, Mecklenburg-Vorpommern) have announced that they will not participate in the scheme. In a policy paper it has been shown that not only the access to regular health insurance cards but also the scope of benefits awarded highly impact the access to health care in practice in the different Federal states.[15]
It has to be pointed out, however, that even in a Federal State like Brandenburg, where almost all municipalities are issuing health insurance cards, the policy does not apply to asylum seekers in initial reception centres, which fall under the responsibility of the Ministry of the Interior. Due to the recently extended obligation to stay in these centres, this affects many asylum seekers for a substantial amount of their asylum procedure (see Obligation to stay in initial reception centres). This means that they cannot access a medical professional of their choice as they depend on the medical personnel present in the initial reception centres. While nurses are present daily in initial reception centres Eisenhüttenstadt and Doberlug-Kirchhain, medical doctors are only on site three days a week.[16] A further practical problem reported is the fact that the medical staff is very restrictive in referring patients to medical specialists. This makes it almost impossible for asylum seekers to meet the legal requirements for the proof of medical conditions in asylum procedures, which explicitly requires a qualified certificate from a medical specialist.[17]
Similarly, in Bavaria, access to health care is rendered extremely difficult for asylum seekers living in AnKER Dependancen. There is often no general practitioner in the Dependancen and residents have therefore to receive care in the main AnkER building, which can be located miles away. Moreover, the doctor present in an AnKER centre is usually a general practitioner and does not provide medical reports, while access to specialised doctors can only take place following a referral from the general practitioner.[18] As seen above, this problem is not specific to AnKER centres, but also prevalent in other reception centres.
According to Section 1a of the Asylum Seekers Benefits Act, reception conditions can be reduced for reasons defined in the law (see Reduction or withdrawal of reception conditions). Even if benefits have been reduced, however, asylum seekers remain entitled to medical treatment pursuant to Section 4 of the Asylum Seekers’ Benefits Act. However, treatment pursuant to Section 6(1) of the Asylum Seekers’ Benefits Act is not accessible in these cases.
Specialised treatment for traumatised asylum seekers and victims of torture can be provided by some specialised doctors and therapists and in several specialised institutions (Treatment Centres for Victims of Torture – Behandlungszentren für Folteropfer). Since the number of places in the treatment centres is limited, access to therapies is not always guaranteed. In 2020, access to over 9,720 of applicants was refused, and others had to wait an average of 6,73 months to start treatment. The treatment centres have to cover most of the costs for therapies (96,7%) through donations or other funds since therapies are often not covered by the health and social authorities for asylum seekers.[19] Large distances between asylum seekers’ places of residence and treatment centres may also render an effective therapy impossible in practice. The Psychosocial Support Centres for Refugees and Victims of Torture (BAFF) criticises that Germany is not meeting its obligations under international law. The BAFF calls for financial stability for psychological support programmes, funding for translation within these programmes and access to regular health insurance cards everywhere in Germany.[20]
Access to treatment for persons suffering mental health problems is available for refugees and beneficiaries of subsidiary protection under the same conditions as for Germans.[21] In practice, however, access to specialised treatment for traumatised refugees or survivors of torture is difficult. According to the Psychosocial Support Centres for Refugees and Victims of Torture (BAFF), refugees face many barriers in the access to specialised treatment.[22] Often access to specialised centres is not available, since only 47 Psychosocial Support Centres for Refugees and Victims of Torture exists in Germany, which have long waiting lists and may be located far from the place of residence of the person in need.[23] These centres prefer to take in asylum seekers without any secured residence permit but still, access is quite complicated. In 2020, only 4.1% of the persons potentially in need could be accommodated in Psychological Support Centres for Refugees and Victims of Torture and had to wait in average 7.2 months for treatment.[24] In psychological care facilities which are not specifically trained for assisting refugees and victims of torture, persons in need may face language or cultural barriers which may lead to misunderstandings with non-trained interpreters or psychologists.[25] The BAFF has persistently criticised the German government for not meeting their obligations under international law concerning the treatment of asylum seekers and victims of torture. They further criticise that the Psychological Support Centres for Refugees and Victims of Torture are all based on private initiatives and have no stability in funding. They run on annual funding from the Federal states (40.7%), from the Federal government (7.0%) and only 6.0% are financed through the regular social insurance system.[26] In 2023, the Federal government announced to cut the funding from EUR 17.5 million to EUR 7 million, constituting a cut of nearly 60%, which would heavily affect the already insufficient structures, according to the BAFF.[27] After political negotiations, the cuts were reduced to EUR 4 million, leading to a funding sum of EUR 13.5 million for 2024.[28]
For information on how the Covid-19 pandemic impacted the access to health care, see the AIDA 2022 update.
[1] Section 4(1) 1st Sentence Asylum Seekers‘ Benefits Act.
[2] Section 4 Asylum Seekers’ Benefits Act.
[3] Section 4(2) Asylum Seekers‘ Benefits Act.
[4] Section 6(1) Asylum Seekers’ Benefits Act.
[5] However, the reduction of benefits may apply for more than 18 months (i.e., without any time limit) to persons who have ‘abused the law to affect the duration of their stay’.
[6] Recommendation for a resolution and report of the Committee on Home Affairs and Community (4th Committee) on the Federal Government’s draft bill of the Act to Improve Removals (Entwurf eines Gesetzes zur Verbesserung der Rückführung (Rückführungsverbesserungsgesetz), available in German at: https://bit.ly/3T2zNT7.
[7] Higher Administrative Court Baden-Württemberg, Decision 7 S 920/98, 4 May 1998.
[8] Georg Classen, Leitfaden zum Asylbewerberleistungsgesetz (Guideline to the Asylum Seekers’ Benefits Act), September 2018, available in German at: https://bit.ly/3ef7zwI, 13.
[9] ProAsyl, #GesundheitFürAlle – Schluss mit der diskriminierenden Gesundheitsversorgung von Geflüchteten!, available in German at: https://bit.ly/3wiXaPn.
[10] Aertzederwelt.org, Gesundheit von schutzsuchenden Menschen gefährdet: Zeitraum für abgesenkte Sozial- und Gesundheitsleistungen für Asylsuchende (AsylbLG) darf nicht verlängert werden!, 04 January 2024, available in German at: https://bit.ly/3T3gmtz; Aertzeblatt.de, Ärzte und Psychotherapeuten kritisieren Einschränkung der Gesundheitsversorgung für Asylbewerber, 24 January 2024, available in German at: https://bit.ly/3OJcSJV.
[11] Regional Social Court Hesse, Decision L 4 AY 9/18 B ER, 11th July 2018, available in German at: https://bit.ly/471UTF2; Regional Social Court Mecklenburg-Vorpommern, Decision L 9 AY 13/19 B ER, 28th August 2019, available in German at: https://bit.ly/4asqdzK.
[12] A study published in early 2022 gives an overview of the regulations and practices in place in the Federal States: Katja Lindner, ‘Gesundheitsversorgung von Asylsuchenden In den Bundesländern. Rahmenbedingungen und Reformbedarfe’, MIDEM-Policy Paper 01/22, available in German at: https://bit.ly/42RwOjN.
[13] Gesundheit für Geflüchtete, Healthcare vouchers, available at: https://bit.ly/2BXoxme; Georg Classen, Leitfaden zum Asylbewerberleistungsgesetz (Guideline to the Asylum Seekers’ Benefits Act), September 2018, available in German at: https://bit.ly/3iJEDAB, 13.
[14] See overview of Federal States, see Gesundheit für Geflüchtete, Regelung in den Bundesländern, available at: https://bit.ly/2U7GRRL.
[15] K. Lindner, Gesundheitsversorgung von Asylsuchenden in den Bundesländern – Rahmenbedingungen und Reformbedarfe, January 2022, available in German at: https://bit.ly/42RwOjN, 17ff.
[16] Information provided by local social workers of Komm Mit e.V. June 2020.
[17] Section 60(7) in conjunction with Section 60a(2c) Residence Act.
[18] ECRE, The AnkER centres Implications for asylum procedures, reception and return, April 2019, available at: https://bit.ly/2W7dICZ.
[19] BAfF, Versorgungsbericht – Zur psychosozialen Versorgung von Flüchtlingen und Folteropfern in Deutschland, 2022, available in German at: https://bit.ly/3HNgZSx.
[20] BAfF, Versorgungsbericht – Zur psychosozialen Versorgung von Flüchtlingen und Folteropfern in Deutschland, 2022, available in German at: https://bit.ly/3HNgZSx.
[21] Section 92 (6a) Social Code V.
[22] BAfF, Traumasensibler und empowernder Umgang mit Geflüchteten ein Praxisleitfaden, 2022, available in German at: https://bit.ly/48jfWDO, 35.
[23] BAfF, Flucht und Gewalt, Psychosozialer Versorgungsbericht 2023, available at: https://bit.ly/49jWoQM, 10.
[24] BAfF, Bundesregierung will psychosoziale Unterstützung für traumatisierte Geflüchtete um fast 60% kürzen, available in German at: https://bit.ly/3SFLBtf.
[25] BafF, Traumasensibler und empowernder Umgang mit Geflüchteten ein Praxisleitfaden, 2022, available in German at: https://bit.ly/48jfWDO, 36.
[26] BAfF, Flucht und Gewalt, Psychosozialer Versorgungsbericht 2023, available at: https://bit.ly/49jWoQM, 11.
[27] BAfF, Bundesregierung will psychosoziale Unterstützung für traumatisierte Geflüchtete um fast 60% kürzen, available in German at: https://bit.ly/3SFLBtf.
[28] Diakonie Deutschland, Bundeshaushalt 2024, available in German at: https://bit.ly/3UEjCwF.